headache after head injury - clinical pearls...botox pros & cons pros –no meaningful...

Headache after Head Injury

- Clinical Pearls

Jonathan Gladstone, MD FRCPC

Director, Gladstone Headache Clinic

Head Injury Specialist, Neurology Service and

Complex Injury Outpatient Rehabilitation Program,

Toronto Rehabilitation Institute,

Co-Director, Headache Clinic, Hospital for Sick Children

Director of Headache Medicine, Cleveland Clinic Canada,

Consultant Neurologist, Toronto Blue Jays

Consultant Neurologist, Toronto Raptors

Learning Objectives

1. Discuss the historical and current controversies

2. Review PTH diagnostic criteria, characteristics , risk factors, perpetuating factors

3. Highlight the Approach to the Patient With PTH

4. Explore Pearls & Pitfalls in PTH Management

How Common are Head Injuries?

150,000 Ontarians

diagnosed with

concussions

annually

Majority of head

injuries are mild

What are the Most Common

Causes of Head Injury?

Post-Traumatic Headache:

A look back through the centuries

Historical Aspects of Concussion/PTH

19th Century

– Psychoneurosis & Compensation Neurosis

Vs

– Traumatic Neurosis & Railway Spine and Brain

21st Century

– Malingering, Somatic Symptom Disorder

vs

– Post-Concussion Syndrome

Dr. Harvey Cushing on

Post-Concussive Symptoms - 1908

“Although no objective signs

accompany these complaints,

they are so uniform from case

to case that the symptoms

cannot be regarded as other

than genuine”.

Courtesy of Dr. John Edmeads

Dr. Walter Dandy on

Post-traumatic Symptoms - 1932

“Although the blow is

unquestionably the precipitant,

the underlying cause is always

the patient’s mentally inferior

background, largely an

hereditary acquisition”.

Courtesy of Dr. John Edmeads

20th Century View

Miller, 1961

– “The most consistent clinical feature is the subject’s

unshakable conviction of unfitness to work

(i.e compensation neurosis)

Symonds, 1962

– It is, I think, questionable whether the affects of concussion,

however slight, are ever completely reversible

(i.e. traumatic neurosis)

Courtesy of Dr. Randolph Evans

How Do You Diagnose PTH?

ICDH-3 Classification

Headache attributable

to head

and/or neck trauma

“Headache Attributed to Head

and/or Neck Trauma”

5.1 Acute headache attributed to traumatic injury to the head

5.2 Persistent headache attributed to traumatic injury to the head

5.3 Acute headache attributed to whiplash injury

5.4 Persistent headache attributed to whiplash injury

According to ICHD-3, to meet criteria for

PTH, the headache must begin within what

time frame from the Head Injury?

A. 24 hours

B. 72 hours

A. 1 week

B. < 30 days

5.2 Persistent Headache Attributed to

Mild Head Injury

A- headaches, no typical characteristics known

B- head trauma with all of : • Either no loss of consciousness, or if it occurred < 30

min in duration

• Glasgow Coma Scale 13 or more

• Symptoms and/or signs diagnostic of concussion

C- headache develops within 7 days of trauma

D- headache continues for > 3 months post trauma

What % of Individuals Develop

Persistent Headache After a HI?

How Does a Head Injury Cause PTH?

Mechanism of Concussion -

Through the Centuries

Queyrat 1657 – commotio cerebri

Littre 1705 – circulatory failure

Petit 1774 – nerve cell shock

Baudens 1836 – molecular vibration

Trotter 1924 – acute compressive anemia

Courtesy of Dr. Randolph Evans

Concussion: Metabolic and Structural Consequences

Johnson, V.E., et. al. Exp Neurol 2012:

Proposed Mechanisms of PTH

Injuries to

– Scalp

– Skull

– Dura

– Specific Nerves of the Head/Neck

– Discs

– Facet

– Bones

– Ligaments

– Muscles

– Sympathetic nerve fibers of

the arterial vessels

– TMJ

Cortical Spreading Depression

Release of Excitatory neurotransmitters

Release of Inhibitory Neurotransmitters

Increased Intracranial Pressure

Decreased Intracranial Pressure

Impaired cerebral vascular autoregulation

Impairment of the ascending and descending pain modulatory systems

What Factors Maintain and

Perpetuate PTH?

Proposed Mechanisms of PTH

Initiation • Physical Factors

Maintenance or Perpetuation • Physical Factors

• Medical Factors

• Situational Factors

• Psychological Factors

• Personality Factors

• Disability/Compensation Factors

Risk Factors for PTH

Milder Trauma ?

Age ?

Female Sex ?

Lower SES, Intelligence?

History of migraine

Family hx of migraine?

Previous head injury

Depression and anxiety

Somatization

Catastrophizing

Maladaptive coping

What Types of Headaches

Develop after a Head Injury?

Why Types of Headache

Occur in PTH?

NEW headache

EXACERBATION of underlying headache

Types of PTH

Migraine

Tension-type headache

Unclassifiable

Cervicogenic

Occipital Neuralgia, Supraorbital Neuralgia, Infraorbital Neuralgia

Other (cluster, hemicrania continua)

Tension-Type Headache

Recurrent similar headache

Last from 30min – 7 days

At least 2 of:

- pressing/tightening

- mild/mod intensity

- bilateral

- no change with exercise

Both of the following

- No N/V

- only 1 of photo/phonophobia

Migraine

Recurrent headaches

Last 4-72 hrs untreated

> 2 of the following

- unilateral

- pulsating

- mod-severe intensity

- aggravated by (or causes avoidance)

of exertion

> 1 of the following

- nausea +/- vomiting

- photo- + phonophobia

No evidence on history or physical of another cause

Idiopathic Stabbing Headache

Head pain occurring as a single

stab or volley of stab

Stabs may last for up to a few

seconds and recur irregularly

No accompanying symptoms

Exertional Headache

A. Pulsating headache meeting B and C

B. Lasting from 5 minutes to 48 hours

C. Brought on by and occurring only during

or after physical exertion

How Do You Approach PTH?

PTH:

A Challenging Situation

Can’t see it

– CT, MRI, EEG typically all normal

Can’t touch it

– Physical examination typically normal

Can’t quantify it

– Purely subjective

How Do You Approach PTH?

– Take a Good History

– Review Medical Brief and Obtain Ancillary Info

– Screen For and Address

• Insomnia, Depression, Anixety, PTSD

• Medication Overuse

– Look for Malingering/Compensation Issues

– Understand and address patient’s questions & concerns

– Normalize, Impart Optimism

– Refer when appropriate

Pearls and Pitfalls in the

Management of PTH?

Pearl #1

Most doctors don’t how

To diagnose and treat

Post- traumatic headache

Pearl #2

Chronic Pain Clinics

Are Usually a Very Good

Option to Assist

Individuals with Post-

Traumatic Headaches

Pearl #3

Pain Does NOT

Need to be Medicated to 0/10

Medications for Headache

Can CAUSE More Headaches

Simple analgesic >15 days month

Combination meds >10 days/month

Opiods >10 days/month

Ergotamine >10 days/month

Triptans > 10 days/month

Pearl #4

There are published guidelines to assist

doctors when treating a patient with PTH

- Ontario Neurotrauma Guidelines for the

Management of Persistent Symptoms

Following Concussion / mTBI

Pearl #5

The Pendulum Has Swung Too Far

Towards Rest

Pearl #6 Concussion Has Become a Business –This is

Disgusting and You Must Be Part of the Solution

Pearl #7 - The Person To Whom the Injury

Happens Is The Most Important Factor

How Do You Treat PTH?

1. Education & Goal Setting

2. Screen for and treat co-morbidities – Mood, Anxiety, Insomnia

3. Non-pharmacologic!!! – Lifestyle strategies

– Mindfulness, Relaxation

– Psychotherapy, CBT

– Physical

4. Medical – Acute

– Prophylactic

– +/- Interventional

ACUTE MEDICATIONS

Nonspecific

NSAIDs, Acetominophen, ASA

Combination analgesics (with caffeine)

AVOID T#1, T#2, T#3, Percocet, Oxycocet !!!

AVOID Tramacet, Tramadol, Oxycontin, Fiorinal !!!

Migrainous

Triptans

Anti-emetics

ACUTE MEDICATIONS

Over-the-Counter:

Advil or similar ≤ 3 days per week

Tylenol ≤ 3 days per week

Aspirin/Alka-Seltzer ≤ 3 days per week

Obey daily limits!

Alternate OTC analgesics

Combine Alka-Seltzer/ASA/Advil with Tylenol to

avoid excessive consumption of any 1 analgesic

ACUTE MEDICATIONS

Triptans

≤ 10 days per month

Axert 12.5 mg, Maxalt 10 mg, or Relpax 40 mg

Wafer (Maxalt/Zomig),

Nasal Spray (Imitrex, Zomig), Injection (Imitrex)

May combine with NSAIDs/ASA

May combine with anti-emetics (Gravol,

Metoclopramide, Ondansetron)

When Should Prophylactic

Therapy Be Considered?

GOALS OF PREVENTIVE

TREATMENT

Decrease attack frequency intensity, and

duration

Improve responsiveness to acute Rx

Improve function and decrease

disability

Preventive Medications

Antidepressants

– TCAs (amitriptyline, nortriptyline)

Beta blockers

– Propranolol

– Nadolol

Anticonvulsants

– Topiramate

– Gabapentin

Interventional

– Botulinum toxin A (BOTOX)

– Nerve Blocks

Neutraceuticals

– Riboflavin, Magnesium

– Melatonin

Miscellaneous

– Sibelium

– Sandomigran

Pearls for Preventing Headache

• Prescribe reality

• Primum non nocere

• Try for “two for’s”

• Start low; go very slow

• Persist, persist, persist

Amitriptyline/Nortrtiptyline

PRO

Old

Inexpensive

Effective

Helps with sleep and neuropathic pain

Con

Obesity

Sedation

Postural lightheadedness

Constipation

Dry Mouth

Cardiac arrhythmias

Glaucoma

Urinary Retention

Topiramate (Topamax)

PRO

Effective (primarily migrainous headache)

Weight loss

Con

Cognitive and language difficulties

Paresthesias

Weight Loss

More expensive

Beta-Blocker

PRO

Old

Inexpensive

Effective (migrainous, exertional)

Con

Hypotension

Low heart rate

Postural light-headedness, pre-syncope

Exercise Intolerance

Sexual dysfunction

Weird dreams

BOTOX Pros & Cons

PROS

– No meaningful side-effects

– Once every 3 months

– No daily medications

– Compliance

– Evidence

CONS

– Injections

– Toxins and Fear

– Cosmetic Bias and MOA uncertainty

– Lack of Access

– Lack of Awareness

PTH and the Future

PTH is real and,

for a minority, can be long-lasting!

20 year old female

Club-level gymnast

Vault injury

Constant 24/7 headaches for 5 years

How Do You Approach PTH?

– Take a Good History

– Review Medical Brief and Obtain Ancillary Info

– Screen For and Address

• Insomnia, Depression, Anixety, PTSD

• Medication Overuse

– Look for Malingering/Compensation Issues

– Understand and address patient’s questions & concerns

– Normalize, Impart Optimism

– Refer when appropriate

A Team-Based Approach is Optimal

to Evaluate and Manage Persisting

Symptoms Following mTBI

Neurologist Psychiatrist Physiatrist Neuropsychologist and Psychology Psychometrist Occupational Therapist Physiotherapist Neuro-otologist (ENT) Neuro-ophthalmologist Sleep Medicine Neurosurgery Diagnostic Investigations (Neuroimaging, Sleep Study, EMG/NCS, EEG) Speech-language pathology Kinesiology Pharmacist

Neurology Service & CIOR at TRI

QUESTIONS?